Page 114 - Journal of Structural Heart Disease Volume 5, Issue 4

Meeting Abstracts
176
2 defects, 23 cases was having 3 defects. 41% of cases was associated with aneurysm of the interatrial septum. Mean diameters of larger and smaller defects were 15.7 ± 4.5 (9-30)mm and 6.3 ±2 (2-9) mm respectively. Mean distance between defects was 7.4±3.6 (2-14) mm. Stretch diameter obtained by balloon sizing was 19 ±5.7 (8-34) mm. As their defects were close to each other standard transcatheter ASD closure procedure was performed in 52 cases(43%). In 28 cases, subsequent to balloon sizing defects got closer to each other so single device was able to occlude them. In 26 cases following the septoplasty with low pressure balloons, defects became nearby so occlusion with a single device was possible. While Multifenestrated/PFO device was used in 6 cases, double device was used in 6 cases. One case managed with three devices. Mean diameters of devices were 19.5 ± 5 (8-36) mm. Immediate complete occlusion was achieved in 83 (70%) cases and one year after the pro- cedure minimal residual shunt was detected only in 1% (no: 12) of cases. Among 3 cases in whom device migration was detected, surgical defect closure was performed in one, in the other two cases device was catched with a snare catheter and the procedure was completed with a larger device with the same route. At mean follow-up of 50±32 (2-156) months, no further complications occurred.
Conclusion: When <8 mm of tissue separated the defects, it is advised to use single device, however usage of >1 device should be suggested if the tissue separating the defects was >8 mm. Oversizing the larger defect or septo- plasty with low pressure balloons which brings the defects closer reduce the incidence of multiple device usage. Transcatheter closure of multiple interatrial defects is feasi- ble, effective, and safe.
Case: A 64-year-old woman presented with episodes of chest pain, hemoptysis, and hypertension and was found to have a 5 cm pseudoaneurysm of the left subclavian artery on chest CTA. She had previously undergone pal- liation of a severe coarctation with an 18mm Hemashield left subclavian to distal descending thoracic aortic graft approximately 10 years prior, and reported a history of chest pain and hemoptysis for ~ 1.5 years. Prior workup had revealed no occult chest malignancy or infection, but a bicuspid aortic valve without AR or AS. Brain imaging revealed a hypoplastic left posterior circulation and domi- nant right vertebral artery. True 3D analysis was performed on an Echo Pixel workstation and endovascular strategy devised. Following multidisciplinary review, given the morbid nature of a surgical approach, decision was made to approach the lesion endovascular with a back-up hybrid approach.
Procedure: In the hybrid operating room, two orthogo- nal fluoroscopic views were obtained to perform 2D/3D fluoro-CT fusion to register and import the pre-operative gated CT. Overlay of the CT images was then used to guide retrograde crossing of the coarc with a Wholley wire which was then snared to form an arterial-arterial loop via right radial access for optimal support. The coarc was then ini- tially treated with a 6mm Mustang balloon to allow retro- grade passage of a 16 French Mullins sheath. A 24x6cm covered CP stent was then deployed across the take-off of the left subclavian artery and coarctation by CT-overlay guidance. Left subclavian angiography (via left radial access) demonstrated exclusion of the ostium of the sub- clavian artery. 28mm and 31mm overlapping Gore C-Tag stent grafts were then deployed to cover from the left carotid and over the distal return site of the prior subcla- vian graft. Finally, a 16mm Amplatzer Vascular Plug 2 was deployed retrograde from the left radial in the subclavian artery proximal to the thyrocervical trunk to exclude retro- grade filling of the pseudoaneurysm after which a surgical left carotid to subclavian bypass was performed to ensure perfusion of the left arm.
Follow-up: One month post-procedure, the patient no longer requires anti-hypertensives and reports normal left arm function and no further chest pain or hemopty- sis. Repeat CT imaging demonstrates no opacification of the pseudoaneurysm and no endograft leak.
Conclusion: Import of advanced imaging into the hybrid operating room and cath lab can facilitate complex endo- vascular interventions by potentially reducing contrast, fluoroscopy, and cineangiography as well as providing 3D context to fluoroscopy. 2D/3D fusion workflow can
149. CT-GUIDED
PSEUDOANEURYSM
PALLIATION OF COMPLEX COARCTATION
Zhongyu Li1, Charudatta S. Bavare2, John M. Neill2, Michael Reardon2,1, Thomas E. MacGillivray2, Ponraj Chinna Durai 3, C. Huie Lin2,1
1Houston Methodist Research Institute, Houston, USA. 2Houston Methodist Hospital, Houston, USA. 3Siemens Medical Solutions USA, Inc., Princeton, USA
Arteriopathy can complicate the course of patients with coarctation of the aorta both early and late after inter- vention. Certain forms of surgical palliation have been associated with late development of aneurysm and pseu- doaneurysm. We report successful advanced-imaging guided re-intervention of coarctation and pseudoaneu- rysm late after surgical palliation.
ENDOVASCULAR LATE AFTER
REPAIR OF SURGICAL
Journal of Structural Heart Disease, August 2019
Volume 5, Issue 4:75-205